Rapid Response Teams and End-of-Life Care. James Downar, MDCM, MHSc, FRCPC Critical Care and Palliative Care, University Health Network, Toronto

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1 Rapid Response Teams and End-of-Life Care James Downar, MDCM, MHSc, FRCPC Critical Care and Palliative Care, University Health Network, Toronto

2 Conflicts of Interest To place your ad here, please call x8577

3 You are on service with the RRT 9pm 65M- Metastatic NSCLC Relapse- no chemo/radio option Pneumonia- 3d abx RRT- RR>30, O 2 sat 90% on 40% FM Short sentences After discussion - no ICU, no intubation RRT to follow for 24h Did we improve his EOL care?

4 Does the RRT improve care? Improvements in single-centre studies Unclear effect in multicentre RCT, metaanalyses What about EOL care? Jones et al. NEJM 2011;365: Chan et al. Arch Int Med 2010;170:18-26.

5 What about EOL Care?

6 RRT and NFR/DNR Orders Retrospective review of RRT activations NFR order would have been appropriate in 23% Parr et al. Resuscitation 2001;50:39-44.

7 RRT and NFR/DNR Orders Retrospective analysis of 105 deaths 95% were NFR (DNR) at time of death 35 seen by RRT Jones et al. Crit Care Resusc 2007;9;151-6.

8 RRT and NFR/DNR Orders MERIT 90% of deaths had NFR order MET hospitals Higher proportion of NFR orders after eventfree emergency calls (8 vs 3%) 10x incidence of NFR orders after event-free calls Chen et al. Resuscitation 2008;79:391-7.

9 RRT, NFR/DNR Orders, and CPR Reduced ineffective CPR Increased DNR orders Higher survival post-arrest No change in hospital mortality Felner and Smith. NEJM 2011;365:

10 RRT and DNR/NFR Orders Multicentre prospective study 652 RRT calls over 1 month 10.8% followed by new DNR order Older, medical patients More likely to occur 5pm to 8am 48% died in hospital 22% discharged home Jones et al. Critical Care Medicine 2012;40:98-103

11 RRT and EOL Care Retrospective pre-post study of ward deaths 61/197 (31%) seen by RRT Post-RRT changes Increases in opioid use, pain scores, chaplaincy Reduced subjective suffering Same benefits seen whether or not RRT deployed Vazquez et al. J Hosp Med 2009;4:

12 RRTs and EOL Care Review of 300 consecutive RRT referrals 3 Academic Hospitals 90% Full Code at time of referral 90 (33%) admitted to ICU within 48h 27 (9.3%) had ward family meeting within 48h 24 (8.3%) had change in resuscitation order (DNR) 25% died during admission Downar et al. J Crit Care In Press.

13 RRTs and EOL Care 24 (8.3%) Family meeting, new DNR 80% called for classic ABC criteria, 63% died Time Palliative Care Spiritual Care PRN Opioids Next 48h 17% 8% 17% 8% Entire Admission 29% 12% 75% 42% 2 patients died without any EOL meds or consultations PRN Sedatives Downar et al. J Crit Care In Press.

14 RRTs and EOL Care Retrospective review of 450 deaths at 3 hospitals 50 in 2005 at each site 100 in 2010 at each site Pathways of care ICU throughout stay Palliative throughout stay Admitted to ward >24h with full resuscitation order Comparisons 2005 vs Availability of RRT RRT vs. no RRT Use of RRT in 2010 Downar et al. Unpublished.

15 RRTs and EOL Care Patients on ward >24h + FC RRT called for 30% of patients RRT involved in 11.1% of pt/family meetings 2005 vs No difference in proportion having pt/family meetings on ward (50% vs. 56%) No difference in proportion having new DNR on ward (49% vs. 56%) Downar et al. Unpublished.

16 Effect of an RRT Consultation Comparison of RRT vs. No RRT (2010) Similar use of opioids (~77%), chaplaincy (~35%) Fewer PC consults (30% vs. 56%) Fewer PRN sedative orders (44% vs. 65%) Similar likelihood of ICU admission, CPR at death Downar et al. Unpublished.

17 Availability of RRT Comparison of 2005 vs More PC consults (only among non-rrt patients) Stepwise multivariable analysis Year of death not an independent predictor of ICU admission Presence of dementia, metastatic cancer, age >80 20% among ICU decedents in % among ICU decedents in 2010 Downar et al. Unpublished.

18 Summary Hospital mortality often preceded by RRT Up to 1/3 of deaths, 1/4 of RRT calls The RRT is involved in decisions to change goals of care ~10% of RRT Calls Unclear whether RRT increasing discussion of goals, or simply taking over role from MRP Reduces aggressive care, but may not improve palliative care RRTs miss many opportunities to facilitate EOL care Secular trend towards better EOL care confounds before-after studies

19 Ethics

20 Should the RRT manage EOL Care? Should the RRT manage CHF? Stable early sepsis? Hypovolemia? PE? Shared responsibility?

21 RRT and Bed Availability Retrospective review of 3494 RRT calls RRT call when reduced bed availability Reduced likelihood of ICU admission- 33% Increased likelihood of change in goals of care- 90% No change in hospital mortality Full ICU = DNR? Empty Beds = Vacancy? Stelfox et al. Arch Intern Med 2012;172:

22 Future Directions EOL Checklists? Communication training? Closer collaboration with palliative care?

23 Thank you for your attention!

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